Dental Examination Waiver Form - Illinois Department Of Public Health
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1Illinois Department of Public Health
DENTAL EXAMINATION WAIVER FORM
Please print:
Student’s Name:
Last
First
Middle
Birth Date:
(Month/Day/Year)
/
/
Address:
Street
City
ZIP Code
Telephone:
Name of School:
Grade Level:
Gender:
Male
Female
Parent or Guardian:
Address (of parent/guardian):
I am unable to obtain the required dental examination because:
My child is enrolled in the free and reduced lunch program and is not covered by private or public dental insurance
(Medicaid/KidCare).
My child is enrolled in the free and reduced lunch program and is ineligible for public insurance (Medicaid/KidCare).
My child is enrolled in Medicaid/KidCare, but we are unable to find a dentist or dental clinic in our community that is
able to see my child and will accept Medicaid/KidCare.
My child does not have any type of dental insurance, and there are no low-cost dental clinics in our community that
will see my child.
Signature _______________________________________________
Date ____________________________
Illinois Department of Public Health, Division of Oral Health
217-785-4899 • TTY (hearing impaired use only) 800-547-0466 •
Printed by Authority of the State of Illinois
P.O.#346086
5M
10/05
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